2008

BENIGN PROSTATIC HYPERTROPHY

Causes of symptoms
Hyperplasia of epithelial and stromal components of prostate
Progressive obstruction of urinary outflow

Increased activity of detrusor muscle

Causes
Frequency, nocturia Poor flow , intermittent stream Hesitation, terminal dribbling

Prevalence
Men > 50 = 41% have symptoms of LUTS Only 18% have a diagnosis Only 10% aware of drugs or

surgery that will help it

Risk factors
Age ? obesity

Differential diagnosis
Poorly controlled diabetes
Neurological disorders Urinary tract infections Abacterial prostatitis Overactive bladder Drugs diuretics, anticholinergics,

antidepressants Lifestyle factors caffeine, alcohol, xs fluids

Abnormal symptoms
The presence of the following symptoms indicates referral to urologist for futher assessment
Urinary incontinence
Retention Dysuria

Haematuria
Acute change in symptoms

Examination
Palpation of abdomen for
enlarged bladder enlarged kidneys constipation

Rectal examination for

Size and consistency of prostate gland

Investigations
Blood tests
Fbc esr U&es

Fasting blood sugar

? PSA level rises with increasing volume of

prostate gland

Urinalysis
Infection haematuria

Investigations
Additional tests as appropriate by GP
Ultrasound for residual urine

volume Urinary diaries

Specialist investigations
Reasons for doing them
Patient reassurance Patient explanation

Objective assessment of symptoms

Diagnostic precision Ranking of treatment options

Prediction of treatment outcome

Specialist investigations
Uroflowmetry
max flow rate and volume of residual urine after

voiding low flow rate indicates need for TURP

Bladder pressure studies

pressure measurement during filling and

emptying (cystometry) gives information on over/under activity of detrusor muscle and obstruction of bladder outlet. Predicts response to treatment. Use antimuscarinics for over activity and turp for bladder outlet obstruction

Specialist investigations
Urinary tract imaging
Ultrasound to estimate residual urine

Urethroscopy
Visual inspection of bladder and uerethra is used

in dysuria or haematuria

Assesment
A validated questionnaire using international prostate symptom scale.
Completion gives total score of 35
17
8 19 20 35

mild moderate severe

Response to the quality of life questionnaire strong predictor or whether intervention is necessary

Scoring system
Ask 7 questions. Answers on scale 0 5 depending

on severity of symptoms For first 6 questions scores are

Not at all < 1 in 5 < half the time About half the time > half the time Almost always =0 =1 =2 =3 =4 =5

Q7 Never = 0, once = 1, 2x = 2, 3x = 3, 4x = 4, 5x = 5

Questions
In last month how often have you
1. 2. Had sensation of not emptying bladder completely Had urge to urinated < 2 hours after previously finished Found you stopped and started again several times Found it difficult to postpone urination Had a weak stream (compared to when aged 30) Had to push or strain to begin urination How many times did you get out of bed per night to urinate

3. 4. 5. 6. 7.

Quality of life
If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?
Delighted
Pleased

0
2 4

1 Mostly satisfied Mixed feelings 3 Mostly dissatisfied Terrible 5

Management
Lifestyle modification
Reduce fluid intake Stop diuretics if poss Avoid xs night time fluid intake/caffeine

/alcohol Empty bladder before long trips/meetings

Management
Treat co morbid contributing

conditions
Diabetes uti

Management
Drug therapy
Alpha blockers Improve bladder and prostate smooth muscle tone More effective than 5 alpha reductase inhibitors All work equally well Tamsulosin and alfuzosin require no dose titration

Management
Drug therapy
5 alpha reductase inhibitors Reduce prostate volume Reduces risk of prostate cancer, increases risk of high grade disease Combined therapy Men with large prostate > 40g or PSA >4 or moderate to severe symptoms combined therapy will prevent 2 episodes of clinical progression per 100men over 4yrs. Much less effective for men with smaller prostates

Management
Drug therapy
Storage problems Men with symptoms of urinary urgency, frequency, small, urine volumes and nocturia in the absence of serious obstructive symptoms are categorised as over active bladder Bladder training Biofeedback Antimuscarinic drugs ( oxybutinin, tolteridine) alone or in combination with treatment for obstructive symptoms

Management
Surgery
TURP Greatest improvement in symptoms 5% severe haemorrhage risk Requires GA Alternative energy sources for TURP Ultrasound Laser microwave

Management
Surgery
Adverse effects of surgery Loss of ejaculation Erectile dysfunction Retrograde ejaculation Incontinence Stricture formation Urinary retention